Annexure 

II 

Self Declaration

1. AMREEN FATHIMA SYED ALEEMULLA

I, _______________________S/D/W/o__________________________ resident of NO 07 E NO
04 4TH STREET NALA ROAD CROSS SHIVAJI NAGAR BANGALORE KARNATAKA 560051
3182 2854 4919 do hereby solemnly affirm and declare as under:-
holding Aadhaar No____________________,

i. That the deponent is the resident of the above said address.

ii. That the correct date of birth of the deponent is 26-06-1989 and the date of birth of the deponent
is wrongly mentioned in the Aadhaar Card bearing Aadhaar No 3182 2854 4919 as 26-06-1999 .
iii. That the deponent wants to get his /her date of birth updated in the Aadhaar Card as 26-06-1989

instead of 26-06-1999 even after utilizing the one-time option for DoB update, for which the deponent is
submitting BIRTH CERTIFICATE (UNDER RBD ACT 1969) as document proof.
iv. That the date of Birth in the Aadhaar Card of the deponent was not correct earlier.
v. That the deponent further declares that no document in support of proof of birth was submitted by
him at the time of Aadhaar Enrolment. However, if so submitted, the document submitted at the time of
updation is not the same as the one submitted at the time of Aadhaar Enrolment.

2. Kindly select whichever are applicable (ü):

S. No Parameter Selection
(i) Current DoB update request is the 1st request for DoB update

(ii) Current DoB update request is second (or greater) request for
DoB

(iii) Date of birth mentioned in the Aadhaar Card at the time of

Aadhaar Enrolment was declared/ approximate and was not verified

(iv) Date of birth mentioned in the Aadhaar Card at the time of

Aadhaar Enrolment was Verified and was not declared/
approximate

3. That the undersigned undertakes that if the document submitted in proof of date of birth is found to
be fraudulent/false/forged/non-genuine, the corresponding Aadhaar number may be deactivated as per Rule
28 of the Aadhaar (Enrolment and Update) Regulations, 2018.
I hereby declare that all the information mentioned above is true to the best of my knowledge
and belief. In case of any discrepancies if arises, the undersigned will be personally held responsible.

Date : 11/01/2022 Name & Signature of Resident.